Malignant Colonic Obstruction Research Articles

P-0220 - Preoperative Stenting Versus Emergency Surgery for Acute Left-Sided Malignant Colonic Obstruction: a Meta Analysis

P-0220 - Preoperative Stenting Versus Emergency Surgery for Acute Left-Sided Malignant Colonic Obstruction: a Meta Analysis

Mo1626 The Newly Nitinol Conformable Self-Expandable Metal Stents for Malignant Colonic Obstruction: a Pilot Experience As Bridge to Surgery Treatment in a Tertiary Referral Center

Mo1626 The Newly Nitinol Conformable Self-Expandable Metal Stents for Malignant Colonic Obstruction: a Pilot Experience As Bridge to Surgery Treatment in a Tertiary Referral Center

Mo1627 Is the Immediate Opening Diameter Related to the Effectiveness of the Evo-C Stent in the Resolution of Acute Neoplastic Colonic Obstruction?

The use of self-expanding metal stents (SEMS) for the treatment of acute malignant colonic obstruction (AMCO) is a well-established practice. However, there are few studies linking clinical success and the degree of immediate postinsertion expansion.

Mo1623 Colonic Stenting or Emergency Surgery for Acute Malignant Colonic Obstruction: Comparison of Long-Term Outcomes in Two General Hospitals

Endoscopic stent placement is widely performed for the management of acute malignant colonic obstruction (AMCO). It can serve both as a ‘bridge to elective surgery' (BTS) in a curative setting as well as definitive palliation in incurable or inoperable patients . Recently published randomized studies revealed no superiority of stent placement over acute surgery as well as a relatively high number of stent-related perforations. These perforations raised concerns of potential tumor seeding, which could influence oncologic outcomes.

Tu1525 Long-Term Outcomes of Stenting As a Bridge to Surgery for Acute Left-Sided Malignant Colonic Obstruction

Tu1525 Long-Term Outcomes of Stenting As a Bridge to Surgery for Acute Left-Sided Malignant Colonic Obstruction

Endo‐laparoscopic approach versus conventional open surgery in the treatment of obstructing left‐sided colon cancer: Long‐term follow‐up of a randomized trial

We previously conducted a randomized trial comparing the endo-laparoscopic approach (i.e. placing self-expanding metallic stents followed by laparoscopic resection) and conventional open surgery in the treatment of obstructing left-sided colon cancer. This study is a follow-up of the previous randomized trial and aims to report the long-term outcomes of the two groups. Forty-eight patients from the randomized trial were followed up in an outpatient clinic with regular monitoring. Patients were compared for clinicopathological variables, disease recurrence and survival rates. Clinicopathological details were comparable between the two groups. During the median follow-up periods of 32 months for the open group and 65 months endo-laparoscopic group, no statistically significant difference was observed between the groups in disease recurrence rate, 5-year overall survival (27% vs 48%, P = 0.076) and 5-year disease-free survival rates (48% vs 52%, P = 0.63). Besides being a safe bridge to subsequent elective laparoscopic surgery, preoperative self-expanding metallic stents insertion does not adversely affect oncological outcomes and patient survival. Based on our data, the endo-laparoscopic approach is the treatment of choice for patients presenting with malignant left-sided colonic obstruction.

A Comparative Study of Short- and Medium-term Outcomes Comparing Emergent Surgery and Stenting as a Bridge to Surgery in Patients With Acute Malignant Colonic Obstruction

The use of self-expanding metal stents as a bridge to surgery in the setting of malignant colorectal obstruction has been advocated as an acceptable alternative to emergency surgery. However, concerns about the safety of stenting have been raised following recent randomized studies. The aim of the current study was to compare outcomes. This was an observational, comparative study. This study was conducted at a tertiary referral center and university teaching hospital. Patients with malignant colonic obstruction (n = 49) treated by either emergency surgery (n = 26) or with stent placement (n = 23) as a bridge to surgery were identified and followed. Short-term outcomes including stoma rates and postoperative morbidity and medium-term oncological outcomes were compared based on an "intention-to-treat" analysis. Patients in both groups were well matched on clinicopathological parameters. Technical and clinical successful stent deployment was achieved in 91% and 83%. This did not adversely impact cancer-specific and overall survival (log rank = nonsignificant). No difference was observed in stoma rates, primary anastomosis rates, perioperative mortality rates, or reoperation rates between the 2 groups. Significantly fewer patients underwent total colectomy in the stent group in comparison with the emergency surgery group (1/23 vs 6/26: p = 0.027). There was no difference in postoperative morbidity (59% vs 66%: p = 0.09). There was a significant reduction in readmission rates in the stent group (5/26 vs 0/23: p = 0.038). The small sample size of this study could lead to type II error. In addition, the study was nonrandomized and demonstrated a limited length of follow-up. Despite a high rate of technical and clinical success in selected patients with colonic obstruction, stenting has no impact on stoma rates. Despite concerns about the rate of stent-associated perforation, stenting does not adversely impact disease progression or survival. Future comparative trials are essential to better define the role of stenting in this setting and to ensure that we are not using costly technology to create an elective operative situation without concomitant patient benefits.

Colonic stenting in the management of malignant intestinal obstruction in elderly patients

Acute intestinal obstruction occurs in 7-30% of patients with colorectal carcinoma, especially if tumour is located at or distal to the splenic flexure. Traditionally, emergency surgical decompression is the treatment option, with the resection of obstructing tumour and often with the creation of defunctioning stoma. Emergency surgical decompression is very effective, but it is associated to high mortality rate, depending on patients comorbidities, anaesthetic and emergency surgery risks. Moreover stoma causes high morbidity rate and a worsening in quality of life, with up to 60% patients that would never be reversed [1]. An alternative to surgery is intraluminal colorectal stenting, first described by Dohmoto in 1991 in 19 patients with non-resectable metastatic rectal cancer. In 1993 Tejero used metallic stents in patients with colon obstruction as “bridge to surgery” [2]. Since its introduction self-expandable metal stent (SEMS) has increasingly been used for malignant colon obstruction and several studies showed its efficacy in relieving the obstruction offering good palliation, and, whenever possible, avoiding emergency surgery and facilitating single-stage surgery, reducing stoma creation. Colonic stenting is also associated to complications, as intestinal perforation, stent migration and clinical failure. Nowadays there is debate concerning five-years survival and cancer-specific mortality: it seems that five-years survival is lower and cancer-specific mortality is higher in SEMS patients compared to urgent surgery patients, because of delayed surgery [3]. The aim of the study was to review our experience and assess the effectiveness of colonic stenting in malignant colon obstruction, as a “bridge to surgery” or as a palliative treatment, in terms of safety, efficacy and clinical outcomes.

Complications and survival in patients undergoing colonic stenting for malignant obstruction

To investigate whether predicting patients that might be at a higher risk for complications might serve to improve the selection of patients undergoing colonic stenting. A retrospective review of consecutive patients who underwent an attempted self-expandable metal stent (SEMS) insertion for malignant colonic obstruction between November 2006 and March 2013. All patients were either referred for preoperative colonic decompression with the intent of a single surgical procedure, or for palliation of the malignant colorectal obstruction for unresectable cancer. Fisher's test or χ(2) test was performed on categorical variables, and the t test for continuous variables. Univariable and multivariable logistic regression were used to examine the association between independent variables and the presence of complications from SEMS insertion. SEMS insertion was attempted in 73 patients. Males comprised 55.71% and the mean age was 67.41 ± 12.41 years. Of these, 65.15% underwent subsequent surgery, while 34.85% received SEMS as palliation for advanced disease. Extracolonic tumors were only 4.76%. The majority of patients had stage IV disease (63.83%), while the remainder had stage III (36.17%). SEMS were successfully inserted in 93.85% (95%CI: 87.85%-99.85%). Perforations occurred in 4.10%, SEMS migration in 8.21%, and stent re-occlusion from ingrowth occurred in 2.74% of patients. The mean duration of follow up for the patients was 13.52 ± 17.48 mo (range 0-73 mo). None of the variables: age, sex, time between the onset of symptoms to SEMS insertion, time between SEMS insertion and surgery, length of the stenosis, location of the stenosis, albumin level, or receiving neoadjuvant chemotherapy, could predict the development of complications from either SEMS insertion nor prolonged survival. None of the variables could predict the development of complications or survival. Further studies are required to identify patients who would benefit the most from SEMS.

経肛門的イレウス管が有効であった悪性大腸閉塞の2例

We report two cases of malignant colonic obstruction that were improved using a trans-anal decompression tube. The first case was that of an 86-year-old woman referred to our department for further investigation of advanced gastric cancer. During an outpatient visit, she was admitted as an emergency because of sudden right flank pain. Computed tomography (CT) showed that the transverse colon had been invaded by the gastric cancer, and the acute symptoms were due to obstruction of the transverse colon. A trans-anal decompression tube was inserted through the obstructed region of the transverse colon, and subsequently symptoms of intestinal obstruction improved. The second case was that of an 84-year-old woman who had been diagnosed with a left renal pelvic tumor. Due to the advanced stage of disease, this patient was followed up at the urology department without curative treatment. Four months after diagnosis, the woman developed abdominal distension and vomiting. CT revealed a left renal mass extending into the descending colon and resulting in colonic obstruction. Symptoms of intestinal obstruction were improved by insertion of the trans-anal decompression tube. Although these patients were at an advanced stage of disease on presentation, decompression using the trans-anal tube was useful in relieving symptoms of malignant colonic obstruction.

Long-term outcome of palliative treatment with self-expanding metal stents for malignant obstructions of the GI tract

Background. Self-expanding metal stents (SEMS) are commonly used in the palliative treatment of malignant gastrointestinal (GI) obstructions with favorable short-term outcome. Data on long-term outcome are scarce, however. Aim. To evaluate long-term outcome after palliative stent treatment of malignant GI obstruction. Method. Between October 2006 and April 2008, nine Norwegian hospitals included patients treated with SEMS for malignant esophageal, gastroduodenal, biliary, and colonic obstructions. Patients were followed for at least 6 months with respect to stent patency, reinterventions, and readmissions. Results. Stent placement was technically successful in 229 of 231 (99%) and clinically successful after 1 week in 220 of 229 (96%) patients. Long-term follow-up was available for 219 patients. Of those, 72 (33%) needed reinterventions. Stent occlusions or migrations (92%) were the most common reasons. Esophageal stents required reinterventions most frequently (41%), and had a significantly (p = 0.02) shorter patency (median 152 days) compared to other locations (gastroduodenal, 256 days; colon, 276 days; biliary, 460 days). Eighty percent of reinterventions were repeated endoscopic procedures that successfully restored patency. Readmissions were required for 156 (72%) patients. Progression of the underlying cancer was the most common reason, whereas 24% were readmitted due to stent complications. Conclusions. Long-term outcome after palliative treatment with SEMS for malignant GI and biliary obstruction shows that 70% had a patent stent until death, and that most reobstructions could be solved endoscopically. Hospital readmissions were mainly related to progression of the underlying cancer disease.

Two-stage resection for malignant colonic obstructions: the timing of early resection and possible predictive factors.

To study potential predictive factors for early radical resection in two-stage resection for left malignant colonic obstruction. Thirty-eight cases of left-sided obstructive colon cancer undergoing two-stage operations were reviewed between January 1998 and August 2008. Patients were classified into two groups (n = 19 each): early radical resection (interval ≤ 10 d) and late radical resection (interval > 10 d). Baseline demographics, post-diversion outcome, perioperative data, tumor characteristics, outcome and complications were analyzed. The baseline demographics revealed no differences except for less pre-diversion sepsis in the early group (P < 0.001) and more obstruction days in the late group (P = 0.009). The mean intervals of early and late radical resections were 7.9 ± 1.3 d and 17.8 ± 5.5 d, respectively (P < 0.001). After diversion, the presence of bowel sounds, flatus, removal of the nasogastric tube and the resumption of oral feeding occurred earlier in the early group. The operation time and duration of hospital stay were both significant reduced in the early group. Complication rates did not differ between groups. The earlier recovery of bowel function seems to be predictive of early radical resection. In contrast, pre-diversion sepsis and more obstruction days were predictive of delayed radical resection.

Laparoscopic Management for Acute Malignant Colonic Obstruction

We aimed to evaluate the feasibility of staged laparoscopic colectomy for acute malignant colon obstruction. Through a laparoscopic approach, emergency blowhole colostomy and subsequent elective resection were performed. There were 14 men and 8 women, ages ranging from 42 to 79 years. All patients underwent laparoscopic blowhole colostomy for fecal diversion. Of these stomas, 6 were located at the splenic flexure, 7 at the descending colon, and 9 at the sigmoid colon. Subsequently, 20 of the 22 patients achieved an elective laparoscopic resection including takedown of the stoma. They were left hemicolectomy in 11 and anterior resection in 9. The mean total length of hospital stay was 20 ± 4.6 days (range, 16 to 33 d) in these 20 patients. The remaining 2 patients did not undergo reversal of the colostomy. The median follow-up period was 23 months. Seven patients died of disease progression and 15 patients remained alive and well. Our results suggest that staged laparoscopic colon resection is a feasible and effective technique for acute malignant colonic obstruction. The length of hospital stay is justified as compared with conventional single-staged resection. Our technique can also be recommended when colonic stenting is not available.

PWE-218 Experience of colonic stenting in a district general hospital

IntroductionA significant number of colon cancer patients present with obstruction which is a surgical emergency. Emergency decompression surgery is associated with 25% mortality.1 Self expandable metal stent (SEMS) provides a...

PTU-264 Providing a colonic stenting service for malignant bowel obstruction: a district general hospital experience

IntroductionThere is growing evidence for the efficacy and safety for the insertion of self expanding metal stents (SEMS) in the treatment of acute malignant colonic obstruction.1 This allows either palliation...

Long-term outcomes of stenting as a bridge to surgery for acute left-sided malignant colonic obstruction.

e14032 Background: Stenting as a bridge to surgery has been increasingly applied in cases of acute left-sided colonic obstruction. This study aims to evaluate both the short and long-term outcomes associated with colonic stenting as a bridge to surgery in patients with obstructing adenocarcinoma of the colon. Methods: Patients with potentially curable acute left-sided colonic obstruction treated with stenting as a bridge to surgery (28) or with emergency surgical resection (39) from January 1998 to December 2008 were identified using a prospectively maintained database. Short-term data on post-operative mortality, morbidity, necessity of intensive care, and length of hospital stay were compared. Disease-free and overall survival data were also analyzed. Results: Patients within the two study arms had similar demographic profiles. Patients receiving preoperative stenting had a higher likelihood of a laparoscopic resection (p&lt;0.001). Further, the emergency surgery group had a higher rate of post-operative complications (p=0.024), rate of ICU admission (p=0.013), and longer total length of stay (9 vs. 12 days, p=0.001). With a median follow-up of 26.5 and 31.3 months for the stenting and surgical resection groups respectively, there was no difference in overall and disease-free survival (overall survival = 30 vs. 31 months, p=0.858; DFS = 13 vs. 12 months, p=0.989). As well, there was no difference in the rate of systemic recurrences (8 vs. 13, p=0.991). Conclusions: Stenting as a bridge to surgery is a safe treatment strategy in the management of patients with acute left-sided colonic obstruction with improved short-term outcomes and comparable long-term oncologic results.

Outcome and safety of self-expandable metallic stents for malignant colon obstruction: a Korean multicenter randomized prospective study

Newly developed uncovered stents are designed to have varied radial force and high conformability to improve clinical outcome and safety. This study aimed to determine and compare the clinical outcome and safety of the Taewoong D-type uncovered stent and the Boston Scientific Wallfex stent. Patients with acute malignant colonic obstruction were treated with a colonic stent. For the purpose of palliation, patients were randomly allocated. For the purpose of bridging, the type of stent was determined by the discretion of the individual doctors. Technical and clinical success and complication occurrence were measured as primary outcomes. From 12 university hospitals, 123 patients with malignant colonic obstruction were enrolled. Of these 123 patients, 58 were treated with colonic stents for palliative purposes. The technical and clinical success rate was 100 % for both stents in the palliative group. Perforation occurred for one patient (3.6 %) in the Wallflex stent group (n = 28) on day 5 and for no patients in the D-type stent group (n = 30). Two cases of migration occurred: one with the Wallflex stent and one with the D-type stent. Stent restenosis occurred for one patient with the Wallflex stent. Preoperative bridging stents were placed in 65 patients. The median time to surgery was 10 days. The technical success rate was 93.4 %, and clinical success was achieved for 86.2 % of the patients. Perforation occurred for five patients: four with the Wallflex stent and one with the D-type stent. The efficacy and safety of the two stents did not differ statistically. The D-type colonic uncovered stent and the Wallflex colonic uncovered stent are effective and safe for both palliative and preoperative bridging therapy used to treat acute malignant colonic obstruction.

Surgical options for neoplastic large bowel obstruction

Colorectal cancer is the third most common cancer in men and the second in women world wide. The majority of the cases of acute neoplastic large bowel obstruction are secondary to colorectal cancer. The other reasons are those from ovarian cancer, bladder cancer, metastatic pelvic cancer, lymphoma, sarcoma. Surgery is the corner stone of CRC cancer treatment and is generally under taken within 6-8 months of diagnosis. The vastmajority of colon cancers can be resected with curative intent. As a result hundreds of thousands of people with resected CRC are candidates for surveillance. As a whole patients with malignant colonic obstruction carry greater risk of poor outcome from the therapeutic procedures and they have shorter surveillance and survival rate, compared with those without complicated course of CRC. Therapeutic strategy in patients with neoplastic large bowel obstruction is mainly determined by location of the obstruction, clinical stage and performance status. Therapeutic strategy in those patients could one of the most challenging clinical scenaria, balansing between advantages/benefits and disadvantages of surgical interven tions and procedures, there prognosis and outcome, tumor biology and last but not least, the quality of life of the patients. SSM, 2012;44(1):21-27

Mo1419 Management of Left-Sided Colonic Malignant Obstruction With Self-Expandable Metal Stents Provides Equivalent Palliation Compared to Surgery With Reduced Complications

Left-sided colonic obstruction secondary to malignancy has traditionally been managed with surgical decompression, often with a colostomy. However, urgent surgical intervention has been associated with considerable morbidity and mortality. Self-expandable metal stents (SEMS) inserted endoscopically have been shown to be an effective alternative to surgical decompression for colonic obstruction and can provide palliation for patients with malignant colonic obstruction who are felt to be poor surgical candidates.

Mo1388 Endoscopic Placement of Self-Expandable Metal Stents for Malignant Colonic Obstruction: A Regional Multicenter Experience in a Large Cohort of Treated Patients

Self-expanding metal stents (SEMS) are a non-surgical option for treatment of malignant colorectal obstruction (CO) in symptomatic patients (pts), both as palliative treatment and bridging to surgery. With reported morbidity and mortality for emergency surgery as high as 39%, SEMS can be useful in resolving acute CO.